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Consent for Treatment, Authorization to Release Medical Information, Assignment of Insurance Benefits for Hospitals and Physicians, and Patient Self Determination Act Checklist

AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize University of Mississippi Health Care or my attending physician or any contractor on behalf of University of Mississippi Health Care to release or disclose information from my hospital medical record pertaining to this hospitalization, in accordance with the policies of this hospital, to insurance companies and/or hospital benefits programs as needed to process this claim.

AUTHORIZATION TO PAY INSURANCE BENEFITS: I hereby assign payment directly to University of Mississippi Health Care and/or to my physicians, benefits payable to me but not to exceed the hospitals or physicians regular charges for this period of hospitalization. I understand that I am financially responsible for charges not covered by this authorization.

FINANCIAL AGREEMENT: For services rendered, I, the undersigned, agree to pay all professional and hospital charges not covered by insurance. I also agree to pay all attorney and/or collection fees necessary for the collection of payment.

MEDICAID PATIENT CERTIFICATION: I certify that I am a recipient of the Medicaid Title XIX program and request that payment of authorized benefits be made on my behalf. I authorize any holder of medical or other information about me to make available to the Division of Medicaid any requested information concerning medical, insurance and financial records related to my hospitalization. I assign the benefits payable for services rendered to the physicians or organization furnishing such services.

STATEMENT TO PERMIT PAYMENT OF MEDICARE BENEFITS TO PROVIDER, PHYSICIAN, AND PATIENT: I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for services rendered to the physicians or organization furnishing such services.

NOTICE TO BENEFICIARIES OF COINSURANCE LIABILITY: When services are provided in hospital departments, the beneficiary will receive a hospital bill and will receive bill(s) from any physician providing professional services. The beneficiary/guarantor will be responsible for coinsurance amounts relating to services billed by the hospital and for coinsurance amounts relating to services billed separately by the physician(s). When services are provided in private physician offices or other non-hospital clinics, the beneficiary is responsible only for coinsurance amounts relating to charges billed by the physicians.

CONSENT FOR TREATMENT: The undersigned authorizes physicians and University of Mississippi Health Care to furnish medical and surgical treatment deemed appropriate including intravenous solutions, blood transfusions, local, general, and regional anesthetics, antibiotics or other drugs deemed necessary. I am aware that adverse unforeseen reactions can occur and may even result in death. I authorize the hospital and my physicians to take photographs, video, audio, or other images or recordings of me or parts of my body while under the care of the hospital for use in medical evaluation, performance improvement, education or research. I further understand that my identity will be concealed and my privacy maintained if the material is used for educational purposes.

I hereby authorize The University Hospitals and Health System and its medical staff: to preserve, use or disclose, or share for scientific or teaching purposes, including research; to use in grafts or transplants upon living person(s); or to otherwise dispose of dismembered tissue, blood, saliva, parts and the like.

RETIREMENT/DESTRUCTION OF X-RAYS: I hereby authorize University of Mississippi Health Care to follow the usual hospital practice of retiring x-ray films and any other graphic data which may be generated during patient’s hospitalization four (4) years after they are generated if a report of the findings is retained for the same period as other hospital records. Further, I hereby release and hold harmless University of Mississippi Health Care, its officers, staff and employees, from any liability connected with this procedure.

VALUABLES: The undersigned hereby releases the hospital from any responsibility due to loss or damage of any valuables that the patient may keep in his/her possession or that may be brought to him/her by other persons.

Consent for Treatment

UNIVERSITY OF MISSISSIPPI MEDICAL CENTER NOTICE OF PRIVACY PRACTICES

Revised Effective Date: January 1, 2020

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED BY UMMC AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ CAREFULLY.

UMMC creates a record of the care and services you receive from us. We call this record your health information. We are required by federal law to keep your health information private. We are also required to provide you with this Notice so that you will know how we use and disclose your health information and how you can get access to this information. This Notice also lists the rights you have regarding your health information. We will abide by the terms of the Notice. This Notice covers your care provided at all UMMC sites of service. We reserve the right to change the terms of this Notice and our privacy practices at any time. Any changes will apply to the health information we already have. When we make changes to our privacy practices, we will post an updated Notice in the places where you may receive treatment from UMMC. You can also request a copy of this Notice at any time, and you may view a copy of the Notice on our web site at www.umc.edu.

Uses and Disclosures That Do Not Require Your Signed Permission

• Treatment. We may use or disclose your health information to doctors, nurses, technicians, medical students, students in other health care fields, or other personnel who are involved in taking care of you. For example, a doctor treating you for chest pain may need to know if you have any existing heart problems so that he/she can make an informed decision concerning your treatment. Additionally, we will/may contact you to (1) remind you of your appointment by calling, e-mailing, texting, or mailing a postcard, or through the patient portal; or (2) discuss treatment alternatives or other health related benefits that may be of interest to you as a patient.
• Payment. We may use or disclose your health information in order to bill and receive payment for services you receive. For example, we will disclose some of your health information to your health insurance company in order to receive payment for your treatment.
• Health Care Operations. We may use and disclose your health information to conduct activities that are called healthcare operations. For example, UMMC personnel or others that perform services for UMMC may review your health information to assure the quality and appropriateness of the care you receive.
• Fundraising Activities. We may contact you about UMMC fundraising activities. You will have the opportunity to opt out of any fundraising material and directions on how to do so will be included in that material. Opting out of fundraising will in no way, affect the care you receive from UMMC.
• Health Information Exchanges. We may make your health information available electronically to other healthcare providers or other healthcare entities for treatment, health care operations, or payment purposes by a state, regional, or national information exchange service. In doing this, we may receive information that they maintain about you so that you may have continuity in health care, treatment, or payments for health care services. We have implemented technologies that allow UMMC and community providers to create, maintain, and share a common electronic health record of their patients for the purpose of coordinating the care of these patients.
• Emergencies. We may use or disclose your health information in an emergency treatment situation.
• Food and Drug Administration. We may use and disclose your health information to a person or company required by the Food and Drug Administration to track adverse events and as otherwise required.
• Workman’s Compensation. We may use and disclose your health information as necessary to comply with workman’s compensation laws and other similar legally- established programs.
• Federal, State or Local Law. We may use and disclose your health information when required by law.
• Government Agencies and Law Enforcement. We may use or share your health information to government agencies for law enforcement purposes or with a law enforcement official.
• Order by a Court, Tribunal or Other Judicial Proceeding. We may disclose your health information when ordered by a court, tribunal or other judicial proceeding, or in response to a subpoena.
• Public Health Reasons. We may use or disclose your health information for public health reasons. For example, we can share health information about you for certain situations such as: preventing disease; helping with product recalls; reporting adverse reactions to medications; reporting suspected abuse, neglect, or domestic violence; or preventing or reducing a serious threat to yours or anyone’s health or safety, such as instances of child and/or elderly abuse or neglect.
• Coroners, Medical Examiners and Funeral Home Directors. We may disclose your health information to a coroner, medical examiner or funeral home director.
• Health Oversight Reasons. We may disclose your health information to the government to be used to oversee the healthcare system.
• Organ and Tissue Donation. We may use and disclose your health information for organ and tissue donation.
• Research. We perform research here. Our researchers may look at your health records to prepare or perform research. They may also share your health information with other researchers. All patient research conducted at UMMC goes through a special process required by law that reviews protections for patients involved in research, including privacy. We will not use your health information or disclose it for research reasons without either getting your prior approval or determining that your privacy is protected.
• Disaster Relief Reasons. We may disclose your health information for the reason of coordinating disaster relief efforts.
• Specialized Government Functions. We may disclose the health information of military personnel and veterans in certain situations to the government. We may also disclose your health information for national security reasons.
• Inmates. We may disclose your health information if you are an inmate of a correctional facility or under the custody of law enforcement.
• Patient Reunions. UMMC contacts specific patient groups for participation in activities or reunions such as the Neonatal Intensive Care unit patients or Transplant patients. If you have been a patient in one of these groups UMMC may use your information to contact you and invite you to reunions/events.
• Health Fairs/Screenings. We may use your information to contact you with the results of any screenings that are not available on the day of the health fair/screening. We may keep a copy of your screenings to verify that you received screenings at a health fair.
• Business Associates. We may disclose your health information to outside companies or persons we have hired to carry out activities for or on behalf of UMMC. We call these outside companies or persons a business associate. For example, when you request a copy of your health information, we may use a copy service to make copies of your health information. . To protect your health information, however, we require the business associate to appropriately safeguard your health information.
• Treatment alternatives. We may use and disclose your health information to manage and coordinate your healthcare and inform you of treatment alternatives and other health related benefits that may be of interest to you. This may include telling you about treatments, services, products and/or other healthcare providers. For example, if you are diagnosed with diabetes, we may tell you about nutritional and other counseling services that may be of interest to you.
• Data Registries. UMMC participates in various data registries that further healthcare operations of UMMC, its mission as an academic medical center and its research mission. Your information may be shared with one or more data registries. If your information is shared with a data registry for the purpose of healthcare operations, the registry is consider a business associate and your health information will be protected as described above under the topic “Business Associate”. If your information is shared with a data registry for purposes of research, your information will be protected as described above under the topic “Research.”/p>

Uses and Disclosures to Which You Have the Opportunity to Object

• People Who Help Take Care of You. We may provide your health information to a family member, friend or other person, if they help take care of you, or if they are responsible for paying for your care, unless you tell us not to. In emergencies, you will not be given the chance to tell us not to provide information to those who take care of you.
• Hospital Directory. If you are admitted to one of our hospitals or units, your name, location within the hospital and religious affiliation will be listed in the hospital directory, unless you tell us not to list you. This information may be disclosed to persons who ask for you by name, such as family and friends, and to members of the clergy.

Other Uses and Disclosures Require Your Prior Written Permission

• Psychotherapy Notes. If we provide you with psychotherapy we will not disclose the notes made by the mental health provider during the therapy services, unless you and your provider give us written permission to disclose the notes.
• Marketing. Marketing information typically may only be used or disclosed by UMMC if you provide UMMC with written permission to use or disclose your information.
• Sale of PHI. In the event that we were to sell your health information.
• Other Uses and Disclosures. Other uses and disclosures will be made, of your health information, only with your written, signed permission. You may take back permission once you have given it and your refusal to provide permission will not be held against you; however, it may prevent us from completing a task you have requested, such an enrollment in a research study or to create a report for your attorney. The request to take back the permission must be made to UMMC in writing. You can take back your permission but only if UMMC has not already acted in reliance of your permission.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

You have the right to inspect and to get copies of your health information. With only a few exceptions, you have the right to inspect, get hard copies of, and, with certain limitations, get electronic copies of your health information. You must make this request in writing. If we do not have your health information, but we know who does, we will tell you where to direct your request. In certain situations, we may deny your request. We let you know if your request is accepted or denied within 30 to 60 days after receiving your written request. If we deny your request will let know in writing, why and explain your right to have the denial reviewed. If you request copies of your health information, we may charge you a fee based on our cost. We may provide you with a summary or explanation of the health information as long as you agree to accept a summary and the cost in advance.

You have the right to request a correction to your health information. If you believe that your health information is incorrect or information is missing, you may request that the information be changed or added. You must make the request in writing. You must also give us a reason for your request. Under certain circumstances, we may deny the request. We will let you know if we accept or deny your request within 60 days of receiving your request. If we deny your request, we will let you know why in writing. We will also explain your right to file a written statement of disagreement with the denial. If we approve your request, we will make the change to your information. We will let you know when the change is made. We will also let concerned parties know when the change is made.

You have the right to request a listing of disclosures we have made of your health information. You have the right to request a listing of all disclosures we have made of your health information without your permission, except those disclosures made for purposes of treatment, payment, or healthcare operations, and those disclosures we made as required by law. We will respond within 60 days of receiving your request. Your request must state the time period desired for the accounting, which must be less than a six-year period prior to your request. The list will contain the date of the disclosure, the name of the recipient and address, if known, a description of the information disclosed and the reason for the disclosure. If you make more than one request in the same year, you will be charged a fee based on cost for each additional request.

You have the right to request restrictions on uses and disclosures of your health information. You have the right to request that we restrict the use and disclosure of your health information. We are not required to agree to your requested restrictions. However, we will honor your request to not disclose your health information to your health plan if the disclosure is for payment or healthcare operations and is not otherwise required by law and the health information pertains solely to items or services for which you have paid out of pocket in full. You may request a restriction by submitting the appropriate UMMC form.

You have the right to choose how we communicate with you. You have the right to request that we communicate with you in a certain way. For example, we encourage you to communicate via your UMMC MyChart account, but you may request that we communicate with you by U.S. mail. We require that you make your request in writing and we will agree to the request as long as we can easily meet it.

You have the right to receive notification in the event your health information is breached. In the event your unsecured protected health information is breached, we will notify you of the occurrence.

If you would like more information on accessing, obtaining a copy or obtaining a listing of the disclosures that we have made of your health information, you may contact UMMC’s release of information.

FILING A COMPLAINT: If you have any questions about this Notice, complaints about our privacy practices or would like information on how to file a complaint with UMMC or the Secretary of the Department of Health and Human Services, please contact: the UMMC Privacy Officer, at The University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216 or call the Information Line at 855-241-2575. You will not be penalized or retaliated against for filing a complaint.

NOTICE OF NONDISCRIMINATION: Patients have the right to: receive considerate, respectful delivery of care regardless of age, race, color, national origin, culture, ethnicity, language, socioeconomic status, religion, physical or mental disability, sex, sexual orientation, gender identity or expression, or manner of payment. If you believe UMMC has discriminated on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or expression, you can file a grievance with UMMC’s Civil Rights Coordinator.

ATTENTION: Language assistance services, free of charge, are available to you. If you need these services, please contact Language Services at 601-984-2027.

Acknowledgement of Receipt of Notice of Privacy Practices